Bonnie S. Dean

INGESTION OF 35% HYDROGEN PEROXIDE

The ingestion of hydrogen peroxide is usually benign. However, the ingestion of greater than 10% hydrogen peroxide can result in significant pathology. Two fatalities are reported in the literature involving children who ingested 27% and 40%. We report a case involving the ingestion of one mouthful of 35% hydrogen peroxide by a 26-month-old female. The child vomited spontaneously. In the Emergency Department the child was lethargic and had an episode of bright red emesis. Several hours later the child experienced a fainting episode followed by a brief respiratory arrest after which she began drooling bright red blood. The initial oral evaluation was negative. Endoscopic evaluation performed 16 hours postingestion revealed erosion of the cardia of the stomach, erythema of the lower esophageal sphincter, and an additional gastric burn. The child was observed for six days and discharged. Follow-up endoscopy performed 12 days postingestion showed only minimal hyperemia in the cardia of the stomach. Exposures to concentrated hydrogen peroxide should be managed aggressively.

Accidental childhood death from diphenhydramine overdosage

A 15-month-old boy presented to an emergency department with tonic clonic jerking of all extremities and dancing eye movements. A history of instant coffee ingestion was obtained at that time. However, a routine blood analysis and toxicology screen showed a diphenhydramine level of 1.0 mg% (lethal, 0.5 mg%). Generalized tonic clonic seizures continued despite conventional therapy. A continuous thiopental infusion was used to control his seizure activity. This child never regained consciousness and was pronounced dead 7 days postingestion.

Coma reversal with cerebral dysfunction recovery after repetitive hyperbaric oxygen therapy for severe carbon monoxide poisoning

The accepted beneficial effects of hyperbaric oxygen (HBO) include a greatly diminished carboxyhemoglobin (COHgb) half-life, enhanced tissue clearance of residual carbon monoxide (CO), reduced cerebral edema, and reversal of cytochrome oxidase inhibition, and prevention of central nervous system lipid peroxidation. Debate regarding the criteria for selection of HBO versus 100% normobaric oxygen therapy continues, and frequently is based solely on the level of COHgb saturation. Patients who manifest signs of serious CO intoxication (unconsciousness, neuropsychiatric symptoms, cardiac or hemodynamic instability) warrant immediate HBO therapy. An unresponsive 33-year-old woman was found in a closed garage, inside her automobile with the ignition on. Her husband admitted to seeing her 6 hours before discovery. 100% normobaric oxygen was administered in the prehospital and emergency department settings. The patient had an initial COHgb saturation of 46.7%, a Glasgow coma score of 3, and was transferred for HBO therapy. Before HBO therapy, the patient remained unresponsive and demonstrated decerebrate posturing and a positive dolls eyes (negative oculocephalic reflex). The electroencephalogram pattern suggested bilateral cerebral dysfunction consistent with a toxic metabolic or hypoxic encephalopathy. The patient underwent HBO therapy at 2.4 ATA for 90 minutes twice a day for 3 consecutive days. On day 7, the patient began to awaken, was weaned from ventilatory support, and was not soon verbalizing appropriately. A Folstein mental status examination showed a score of 26 of 30. Neurological examination demonstrated mild residual left upper extremity weakness and a normal gait. There was no evidence of significant neurological sequelae at 1 month follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)

Philodendron/Dieffenbachia Ingestions: Are They a Problem?

Ingestions involving the philodendron/dieffenbachia members of the Arum family are allegedly associated with the development of intense irritation of mucous membranes, resulting in swelling of the tongue, lips and palate. Although numerous literature citations promote their toxicity, there are few case reports which substantiate a cause-effect relationship between ingestion and resultant symptomatology. To assess the toxic manifestations associated with the ingestion of these plants, a retrospective review of such cases reported to a Regional Poison Information Center was performed. 188 cases were identified and the integrity of the leaf had been broken in all cases. Philodendrons accounted for 67.5% and dieffenbachias for 32.5% of the cases. 72.8% involved children aged 4-12 months. Only 2.1% (4) of the patients were symptomatic (dieffenbachia-3; philodendron-1). In all cases, the symptoms occurred within 5 minutes of the exposure and were of short duration and the outcome was classified as minor. In this 24 month senses of 188 exposures, severe oral complications and the delayed development of symptoms were not observed.

Poison center funding--who should pay?

To illustrate costs associated with poison center closure a survey of lay callers to the poison center and emergency department costs was conducted. For 21 days all callers to a Regional Poison Information Center receiving home treatment were asked the type of health insurance coverage the patient had. This information was documented on the medical record and tabulated. Health care costs were determined by surveying local hospitals. Of the callers, 1,276 (43%) provided insurance information: 928 (73%) of the patients were covered by private insurers; 258 (20%) received state medical assistance and 90 (7%) had no medical coverage. The average emergency department cost of an ingestion exposure was

Ceramic lead glaze ingestions in nursing home residents with dementia

210.75, ocular

Acute phenolphthalein ingestion in children A retrospective review

172.22, and inhalation

Air bags: Lifesaving with toxic potential?

298.03. In the absence of a Regional Poison Information Center responding to 61,000 calls annually, the state would incur a debt ranging from 1.27 to 2.20 million dollars if 60% of those covered under state assistance went to the emergency department. Private insurers would forfeit 4.58 to 7.93 million dollars per year. These cost estimates consider only the emergency department charges, not unnecessary admissions. State government and private insurers clearly are the financial beneficiaries of poison center services which save several times their operating costs.

The effects of penicillin and cephalosporin ingestions in children less than six years of age.

Three cases of acute lead ceramic glaze ingestions that occurred in elderly patients during art therapy classes in nursing homes are reported. Initial blood lead levels were 109 micrograms/dL (5.23 mumol/L), 259 micrograms/dL (10.43 mumol/L), and 85 micrograms/dL (4.08 mumol/L), respectively, and all patients underwent chelation therapy. Two individuals tolerated therapy well and showed no discernable changes from baseline state. One patient with a lead encephalopathy died and is, to the best of our knowledge, the first report of a death directly related to a ceramic lead glaze ingestion. Ceramic lead glaze ingestions among institutionalized patients may be more common than generally appreciated and occasionally are associated with significant morbidity or, rarely, mortality. Simple preventive measures could eliminate the majority of such occurrences.

An extensive review of commercial product labels the good, bad and ugly.

The Patient Management Exchange for this edition of the Journal features a research study on phenolphthalein ingestion done at the Pittsburgh Poison Center. The purpose of selecting this article was twofold. First, the material presented about the management of phenolphthalein ingestion in children is valuable information for health care practitioners working in ambulatory settings. Second, this work is an excellent illustration of how research can be incorporated into ones clinical practice. This study also demonstrates that research does not always involve a long and cumbersome process. Instead, research can evolve from the need of health care professionals to answer a simple question that is raised about a particular aspect of their patient practice.